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Value of hospital resources for effective pressure injury prevention: a cost-effectiveness analysis
  1. William V Padula1,
  2. Peter J Pronovost2,3,
  3. Mary Beth F Makic4,
  4. Heidi L Wald5,
  5. Dane Moran6,
  6. Manish K Mishra7,
  7. David O Meltzer8
  1. 1 Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
  2. 2 Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, USA
  3. 3 Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  4. 4 College of Nursing, University of Colorado, Aurora, Colorado, USA
  5. 5 Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
  6. 6 Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
  7. 7 Community and Family Medicine, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
  8. 8 Department of Medicine, Center for Health and the Social Sciences, University of Chicago, Chicago, Illinois, USA
  1. Correspondence to Dr William V Padula, Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA; wpadula{at}


Objective Hospital-acquired pressure injuries are localised skin injuries that cause significant mortality and are costly. Nursing best practices prevent pressure injuries, including time-consuming, complex tasks that lack payment incentives. The Braden Scale is an evidence-based stratification tool nurses use daily to assess pressure-injury risk. Our objective was to analyse the cost-utility of performing repeated risk-assessment for pressure-injury prevention in all patients or high-risk groups.

Design Cost-utility analysis using Markov modelling from US societal and healthcare sector perspectives within a 1-year time horizon.

Setting Patient-level longitudinal data on 34 787 encounters from an academic hospital electronic health record (EHR) between 2011 and 2014, including daily Braden scores. Supervised machine learning simulated age-adjusted transition probabilities between risk levels and pressure injuries.

Participants Hospitalised adults with Braden scores classified into five risk levels: very high risk (6–9), high risk (10–11), moderate risk (12–14), at-risk (15–18), minimal risk (19–23).

Interventions Standard care, repeated risk assessment in all risk levels or only repeated risk assessment in high-risk strata based on machine-learning simulations.

Main outcome measures Costs (2016 $US) of pressure-injury treatment and prevention, and quality-adjusted life years (QALYs) related to pressure injuries were weighted by transition probabilities to calculate the incremental cost-effectiveness ratio (ICER) at $100 000/QALY willingness-to-pay. Univariate and probabilistic sensitivity analyses tested model uncertainty.

Results Simulating prevention for all patients yielded greater QALYs at higher cost from societal and healthcare sector perspectives, equating to ICERs of $2000/QALY and $2142/QALY, respectively. Risk-stratified follow-up in patients with Braden scores <15 dominated standard care. Prevention for all patients was cost-effective in >99% of probabilistic simulations.

Conclusion Our analysis using EHR data maintains that pressure-injury prevention for all inpatients is cost-effective. Hospitals should invest in nursing compliance with international prevention guidelines.

  • cost-effectiveness
  • nurses
  • health services research

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • Contributors All authors contributed equally to the development of this manuscript.

  • Funding This study was funded by Agency for Healthcare Research and Quality (grant no: 1-F32-HS023710-01).

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval University of Chicago Biological Sciences Division IRB.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The data for this analysis were available to all study authors. They are available to editors and reviewers on request made to WVP.

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